HUD-92422-OHF Financial and Statistical Data For HUD Reporting

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Overview

PRA Statement
Account Groupings
Definitions
Quarterly Reporting Only
Monthly Reporting - 1st Qtr
Monthly Reporting - 2nd Qtr
Monthly Reporting - 3rd Qtr
Monthly Reporting - 4th Qtr

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Sheet 1: PRA Statement

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 4 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The information requested is required in order to receive the benefits to be derived. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Housing and Urban Development, Office of the Chief Data Officer, Attention: Departmental Clearance Officer, 451 7th Street SW. Room, Washington, DC 20410 or email [email protected]. HUD collects this information, pursuant to Section 242 of the National Housing Act and regulations at 24 CFR Part 242, in order to review Section 242 applications to determine eligibility, underwrite insured hospital loans, ensure adequate collateral, process initial/final endorsement, manage FHA’s hospital portfolio, monitor and manage risk, and ensure ongoing compliance with regulations. No confidentiality is assured.

Warning: Any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions.

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Sheet 2: Account Groupings

[Sheet content highlights: account groupings table beginning A6; footnotes beginning A42]
Section 242 Mortgage Insurance for Hospitals Program
ACCOUNT GROUPINGS
The following chart showings the typical accounts that are included in the account heading for entry into the Quarterly Data request. This chart is not intended to restrict the separate accounts that a hospital may have on its balance sheet. Certain headings have been omitted such as Accumulated Depreciation or Net Patient Revenue as the heading itself is self-definitive and standard throughout the healthcare industry. Additional accounts should be classified based on the pattern.
[blank row]
Main Heading	Typical Accounts
Cash and Temporary Investments	Cash Cash on hand Savings Checking Certificates of Deposit (CDs) Marketable securities Investments Short-term investments Assets limited as to use-current portion only
Accounts Receivable, Net	Patient Accounts Receivable net
Accounts Receivable, Gross	Patient Accounts Receivable gross
Due from Related Entities	[blank]
All Other Current Assets	Other Receivable Prepaid Expenses
Hospital Held Non-Liquid Qualified Investments	Alternative Investments
Qualified Liquid Investments	Qualified Liquid Investments • Board Designated for Capital Improvements • Other non-current assets (if investments) LESS amount pledged on line of credit LESS amount pledged on letter of credit LESS amount due to underfunding of self-insured fund LESS amount due to underfunding of pension fund
Limited Use or Designated Assets	Assets limited as to use Debt Escrow Fund Deferred financing costs Restricted assets Investment in affiliates Assets tied up by a Letter of Credit (LOC) Self-insured trust Pension Fund Restricted by Donor PLUS amount pledged on line of credit PLUS amount pledged on letter of credit PLUS amount due to underfunding of self-insured fund PLUS amounts due to underfunding of pension fund Deferred Tax Asset
Mortgage Reserve Fund – Trust Balance	[blank]
Plant, Property, and Equipment	Total Fixed Assets (net of accumulated depreciation) Property and equipment, net Property, Plant and Equipment Land Improvement Real Estate Building Improvement Leasehold Improvements Right of Use (Leased) Assets Construction in Progress With related accumulated depreciation accounts
Accounts Payable	Accounts Payable Trade Accounts Payable Other, Construction & retainage payable
Accrued Expenses	Accrued Expenses • Accrued Salaries & Wages • Accrued Employee Benefits • Accrued interest payable Other Accrued Expenses
Due to Related Entities	[blank]
Current Portion of Long Term Debt and Leases	Current portion of capital debt Current portion of mortgages Current portion of notes payable Current portion of long term lease obligations Current portion of equipment purchases
All Other Current Liabilities	Other current liabilities Payables to 3rd party payors
Long-Term Debt & Leases	Mortgages Payable Lease Obligations Deferred Financing Costs (FASB)
All Other Long-Term Liabilities	Other long-term debt • Minority interest in Consolidated Subsidiary(ies) • Other Non-current • Deferred Revenues • Deferred tax liability
Net Assets without Donor Restriction	Unrestricted Net Assets Common stock issued and outstanding Common stock shares Retained earnings Paid in capital Partner’s Capital Invested in capital assets net of related debt
Net Assets with Donor Restriction	Donor Restricted Net Assets Follow FASB as appropriate
Other Operating Revenues	Other operating revenue Rental income Cafeteria sales Rental of space Amounts received from Related Organizations offset by operating expenses Release of Restricted Assets for operating purposes Certain permitted tax revenues [1] Total Other Operating Revenue
Salaries and Wages	[blank]
Employee Benefits	[blank]
Contract Labor (clinical and non clinical) Expense	Contract Physician Fees Professional Fees
Supplies and Pharmaceuticals Expense	Supplies Drugs
Depreciation Expense (including Lease Amortization)	[blank]
Interest Expense	[blank]
Bad Debt Expense	Follow GASB/FASB as appropriate
All Other Operating Expenses	Purchased services and other contract services Utilities Insurance Other expenses
Non-Operating Revenue	Non-operating revenue Contributions Grants Interest income Investment income net of expense Net realized gains & investment income Net assets released from restrictions for capital assets Gain on disposal of property and equipment Income less expenses of non-mortgaged entities Minority interest in consolidated subsidiary
Non-Operating Expense	Non-operating expense Non-operating losses Change in additional minimum pension liability Loss on sale of assets Loss on disposal of assets Loss on disposal of property and equipment
Extraordinary Items and Income Taxes	Cumulative effect of accounting change Gains or losses on the extinguishment of debt Accelerated depreciation due to the HUD insured project Income taxes unless specifically permitted otherwise Losses or Gains from sale of equipment Losses or Gains from discontinued operations
Unrecognized Gains/Losses	Net unrealized gains & losses
Changes in Restricted Net Assets	Restricted Contributions Restricted Grants Net assets released from restrictions
Other Changes in Fund Balance	[blank]
[blank row]
[1] Tax or provider fee programs where a hospital pays a “fee, tax, or contribution” and then receives increased reimbursement, whether through Disproportionate Share Funds or otherwise, may be included in Other Operating Income. Other recurring tax revenue (e.g., millage-based county support) may be included if permitted by HUD.

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Sheet 3: Definitions

[Sheet content highlights: definitions table beginning A6; footnotes beginning A50]
Section 242 Mortgage Insurance for Hospitals Program
ACCOUNT DEFINITIONS
The following table is the definition of certain accounts. If there is a conflict between the following definitions and the definition in the Regulatory Agreement, the definition in the Regulatory Agreement controls.
The Borrower is required to submit this form for only the Borrower, not the Borrower and other entities. If Assets, Liabilities, Equity, Revenues, or Expenses are excluded from the Borrower (not pledged under the security agreement), then those amounts should not be represented.
[blank row]
Term	Definition
Cash and Temporary Investments	For the Borrower, include all unrestricted highly liquid investments that are readily convertible to cash such as commercial papers and short-term investments that are included in the current asset section of the balance sheet. [see note 2 below]
Patient Accounts Receivable	This is accounts receivable pertaining only to patient care for the Borrower. It is usually displayed net of allowance for uncollectible accounts and contractual adjustments. If the gross amount is given, subtract these items from the gross amount to get to the net accounts receivable figure. Do not include other receivables, grant receivables, miscellaneous receivables or receivables from third party agencies.
Allowances for Contractual Deductions and Bad Debt	Follow FASB/GASB guidance as appropriate for the classification of Contractual Deductions and Bad Debt.
Due from Related Entities	Includes amounts receivable from entities, including Affiliates and Pledged Affiliates, that are either: (a) not consolidated with the Borrower but control, are controlled by, or are under common control with the Borrower; or (b) are consolidated with the Borrower but are excluded from the mortgaged property.
All Other Current Assets	Catch-all category, include current assets that cannot be classified elsewhere. This includes items such as other receivables or prepaid expenses.
Qualified Liquid Investments	For the Borrower: Qualified Liquid Investments are generally made up of marketable securities, Certificates of Deposit (CDs), and bond investments that are undesignated and available for general operational use of the hospital within six months or less if so desired. Qualified Liquid Investments do not include: a) Any accounts, investments, etc. that are part of a self-insurance fund; b) Proceeds of any borrowings including without limitation: (1) any internal affiliate loans regardless of the maturity date, (2) proceeds of any outstanding accounts receivable financing; (3) proceeds from lines of credit, or (4) funds supporting a letter of credit, loan guarantee, etc. c) Investments in any related entity or entity controlled by a related entity; d) Pledges receivable; e) restricted net assets; f) Reserve funds related to an issuance of bonds; g) Amounts shown as an unfunded or underfunded reserve(s); h) Mortgage Reserve Fund(s) or other loan reserve funds; or i) Any items that cannot be clearly identified as meeting the criteria of this definition in the financial statements of the organization. Generally alternative investments are excluded from Qualified Liquid Investments. Investments designated by the board for future use or for general capital improvements and that are not part of the Equipment Replacement Reserve Fund (or similar fund) nor excluded by any of the other categories listed in this definition may be classified as Qualified Liquid Investments and shall not be excluded because of the designation by the board.
Hospital Held Non Liquid Qualified Investments	This account includes amounts that met all of the criteria for Qualified Liquid Investments except: (1) they could not be made available for general operational use within six months, or (2) they were classified as alternative investments.
Limited Use or Designated Assets	For the Borrower, this is the total of the non-current portion of all restricted assets whose use is limited. It includes accounts such as self-insurance reserves or pension reserves. Do not add back the current portion of this item that has been designated as a current asset in the financial statements.
Mortgage Reserve Fund – Trust Balance	For the Borrower, this is the trust account, or account held by the Lender, required by the Borrower’s regulatory agreement.
Plant, Property, and Equipment	This is the total land, land improvements, plant, property, fixed assets, and equipment, moveable equipment, right-of-use assets, medical equipment, and construction in progress recorded on the balance sheet in accordance with Generally Accepted Accounting Principles (GAAP) for the Borrower.
All Other Non-current Assets	Catch-all category, include non-current assets that cannot be classified elsewhere.
Accounts Payable	For the Borrower, this item should reflect what is owed on materials, supplies, utilities, and other personnel expenses. Exclude accrued salaries, wages, employee benefits, professional fees, and accrued interest.
Accrued Expenses	For the Borrower, this item should include amounts not included in Accounts Payable such as payables for salaries, wages, employee benefits, professional fees, and accrued interest.
Due to Related Entities	Includes amounts payable to entities, including Affiliates and Pledged Affiliates, that are either: (a) not consolidated with the Borrower but control, are controlled by, or are under common control with the Borrower; or (b) are consolidated with the Borrower but are excluded from the mortgaged property.
Current portion of Long Term Debt and Leases	For the Borrower, this includes the current portion of all types of debt including current portion of leases (with more than one year of duration) recorded on the balance sheet.
All Other Current Liabilities	Catch-all category, include current liabilities that cannot be classified elsewhere. This includes items such as payables to third party payors.
Long Term Debt and Leases	This should include all debt that is not included in current liabilities including leases that are recorded on the balance sheet for the Borrower. It does not include any related bonds as they are not a part of the Borrower.
All Other Long Term Liabilities	Catch-all category, include non-current liabilities that cannot be classified elsewhere.
Generally Accepted Accounting Principles distinguish the net assets of a corporation with appropriate descriptions depending on the organizational structure of the entity. Section 242 uses the following mapping for the treatment of these items and entering data on the Quarterly Data Request.
Net Assets without Donor Restriction	This should be for only the Borrower. [3 lists below] For profit entities: Common stock issued and outstanding Common stock shares Retained earnings Paid in capital Partner’s capital [space between lists] Not-for- Profit entities Net Assets without Donor Restriction [space between lists] Governmental entities Unrestricted Net Assets Invested in capital assets net of related debt
Net Assets with Donor Restriction	Enter net assets restricted by donor.
Patient Revenue Net of Contractual Allowances and Discounts	Follow healthcare industry practice.
Provision for Bad Debts	Follow FASB/GASB guidance as appropriate for the classification of the Provision for Bad Debts.
Net Patient Service Revenue Net of Bad Debts	Follow healthcare industry practice.
Other Operating Revenue	For the Borrower. (Income from investments, unrestricted contributions, interest income, gains from the sale of assets, non-operating revenues, and extraordinary gains are excluded from operating revenue) In certain case where the dollar amounts are assured and recurring, revenues from taxation may be included. [1]
Total Operating Revenue	Total operating revenue for the Borrower. Total Operating Revenue is defined as: Net Patient Service Revenue plus Other Operating Revenue
Salaries and Wages	Salaries and wages for employees for the Borrower.
Employee Benefits	Enter employee benefits if available.
Contract Labor (clinical and non-clinical) Expense	Contract labor expense includes professional fees of contracted physicians (and clinical staff) that are not employees of the Borrower.
Supplies and Pharmaceuticals Expense	Enter expenses related to the use of supplies and pharmaceuticals.
Depreciation Expense (including Lease Amortization)	The cost of property, plant, and equipment as recognized over the estimated useful life of each class of assets.
Interest Expense	Includes interest costs recognized on obligations having explicit interest rates and interest costs of lease liabilities. This also includes costs resulting from amortization of discounts or premiums and issue costs on debt.
Bad Debt Expense	Follow FASB/GASB guidance as appropriate for the classification of Bad Debt Expense.
All Other Operating Expenses	Catch-all category, include operating expenses that cannot be classified elsewhere.
Non-Operating Revenue	Income from investments net of investment expense, unrestricted contributions, interest income, gains from the sale of assets, non-operating revenues, extraordinary gains, gains from subsidiaries excluded from the Borrower, grant revenues (when there is not an offsetting expense), and non-recurring tax revenues [1] are examples of non-operating income.
Non-Operating Expense	Expenses or losses that are not included as a part of income from operations, such as changes in additional minimum pension liability and loss on sale or disposal of assets.
Extraordinary Items & Income Tax	Include transactions that are unusual in nature and infrequent in occurrence, as well as income taxes incurred by the Borrower.
Net Income	Net Income; Revenues in excess of expenses
Unrecognized Gains/Losses	Include unrealized gains and losses resulting from changes in value of investments reported at fair value.
Changes in Restricted Net Assets	Includes items such as grants, contributions, and donations that carry donor-imposed restrictions. This line item also includes changes resulting from the satisfaction of donor-imposed restrictions.
Other Changes in Fund Balance	This is a catch-all field for any other cause for changes in Net Assets. It is equal to the current period total net assets less the amount of total net assets from the prior year annual financial statements, less unrecognized gains and losses, less changes in restricted assets. Please provide an explanation for any “Other Changes in Fund Balance”.
[blank row]
[1] Tax or provider fee programs where a hospital pays a “fee, tax, or contribution” and then receives increased reimbursement, whether through Disproportionate Share Funds or otherwise, may be included in Other Operating Income. Other recurring tax revenue (e.g., millage-based county support) may be included if permitted by HUD.
[2] The term “Borrower”, synonymous with "Mortgagor," is defined as the original borrower under a mortgage and its successors and assigns.

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Sheet 4: Quarterly Reporting Only

[Sheet content highlights: primary data table A14; Other Information section A151; Certification section A200; footnotes A206; Edit Checks section A213]
OMB Approval No. 2502-0602 (Exp. XX/XX/202X) form HUD-92422-OHF
Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
[ENTER BORROWER LEGAL NAME HERE]			[ENTER FYE HERE]
If monthly reporting is required enter 1, if quarterly enter 2				2
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website www.hud.gov/healthcare or may be obtained from your Account Executive.
(B.) Please contact your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in YELLOW. Items in GREEN are to be filled out only if applicable.
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet.
(F.) The Borrower is required to submit this form for only the Borrower, not the Borrower and other entities. If Assets, Liabilities, Equity, Revenues, or Expenses are excluded from the Borrower (not pledged under the security agreement), then those amounts should not be represented.
(G.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description		1st Qtr YTD	2nd Qtr YTD	3rd Qtr YTD	4th Qtr YTD
Balance Sheet	[blank]	[blank]	[blank]	[blank]	[blank]
Cash & Temporary Investments	[required row]
Gross Patient Receivables	[required row]
Allowances for Contractual Deductions and Doubtful Accounts	[required row]
Net Accounts Receivable	-	$-	$-	$-	$-
Due from Related Entities	[required row]
All Other Current Assets	[required row]
Total Current Assets	-	$-	$-	$-	$-
Qualified Liquid Investments	[required row]
Hospital Held Non-Liquid Qual. Invest.	[required row]
Limited Use or Designated Assets	[required row]
Mortgage Reserve Fund - Trust Balance
Gross Property, Plant & Equipment	[required row]
Accumulated Depreciation	[required row]
Net Property, Plant & Equipment	-	$-	$-	$-	$-
Due from Related Entities (Long-Term)	[required row]
All Other Non-current Assets	[required row]
Total Assets	-	$-	$-	$-	$-
Accounts Payable	[required row]
Accrued Expenses	[required row]
Current Portion of LT Debts and Leases	[required row]
Due to Related Entities	[required row]
All Other Current Liabilities	[required row]
Total Current Liabilities	-	$-	$-	$-	$-
Long Term Debt and Leases	[required row]
Due to Related Entities (Long-Term)	[required row]
All Other Long Term Liabilities	[required row]
Total Long Term Liabilities	-	$-	$-	$-	$-
Total Liabilities	-	$-	$-	$-	$-
Net Assets without Donor Restrictions	[required row]
Net Assets with Donor Restrictions	[required row]
Total Net Assets	-	$-	$-	$-	$-
Total Net Assets + Total Liabilities	-	$-	$-	$-	$-
Income Statement	[blank]	[blank]	[blank]	[blank]	[blank]
Net Inpatient Revenue (1) (6)	[required row]
Net Outpatient Revenue (1) (6)	[required row]
Patient Service Rev net of Contr. Allow. & discounts	-	$-	$-	$-	$-
Provision for Bad Debts	[required row]
Net Patient Service Revenue less Provision for Bad Debts	-	$-	$-	$-	$-
All Other Operating Revenue	[required row]
Total Operating Revenue	-	$-	$-	$-	$-
Salaries and Wages	[required row]
Employee Benefits	[required row]
Contract Labor (clinical and non clinical) Expense	[required row]
Supplies and Pharmaceuticals Expense	[required row]
Depreciation Expense (incl Lease Amortization)	[required row]
Interest Expense	[required row]
Bad Debt Expense (1)	[required row]
All Other Operating Expenses	[required row]
Total Operating Expense	-	$-	$-	$-	$-
Income from Operations	-	$-	$-	$-	$-
All Non-Operating Revenue	[required row]
All Non-Operating Expense	[required row]
Extraordinary Items & Income Tax	[required row]
Net Income	-	$-	$-	$-	$-
Unrecognized Gains/Losses	[required row]
Changes in Restricted Net Assets	[required row]
Other Changes in Fund Balance (2)	[required row]
Net Increase/Decrease in Fund Balance	-	$-	$-	$-	$-
Mortgage Reserve Fund	-	[blank]	[blank]	[blank]	[blank]
Required MRF Balance	[required row]
Actual MRF Balance	-	$-	$-	$-	$-
FHA-Insured Mortgage	-	[blank]	[blank]	[blank]	[blank]
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages	[required row]
Credit Line Usage	-	[blank]	[blank]	[blank]	[blank]
If the Borrower maintains a credit line, provide:	-	[blank]	[blank]	[blank]	[blank]
Security Type (Cash, Investments, Accounts Receivable, Other)	[Row to be filled out only if applicable]	Please select…	Please select…	Please select…	Please select…
Credit Line Amount (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Current Balance Drawn (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Distribution of Assets and Surplus Cash	-	[blank]	[blank]	[blank]	[blank]
If the Borrower has made a Distribution of Assets or a distribution of Surplus Cash (either through specific approval by HUD or via certification of compliance with the Regulatory Agreement), as defined by the Regulatory Agreement, provide the total amount per quarter:	[Row to be filled out only if applicable]
Recurring County or Local Support	-	[blank]	[blank]	[blank]	[blank]
If the Borrower receives recurring county or local financial support, please indicate the amount received. Examples include recurring millage-based payment, or recurring direct payments in support of certain programs.	[Row to be filled out only if applicable]
Net Inpatient Revenue (1)	-	$-	$-	$-	$-
Medicare (including Managed Care)	[required row]
Medicaid (including Managed Care)	[required row]
Commercial Insurance (including non-governmental Managed Care)	[required row]
Self Pay	[required row]
Other	[required row]
Inpatient Statistics	-	[blank]	[blank]	[blank]	[blank]
Total Licensed Inpatient Beds	[required row]
Total Staffed Inpatient Beds	[required row]
Acute Medical/Surgical Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Newborn Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Acute Care Services	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Non-Acute Care	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Swing Bed (SNF)	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Acute Care Only (Excl. Newborn)	-	[blank]	[blank]	[blank]	[blank]
Medicare	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
All Patients	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
Outpatient Utilization	-	[blank]	[blank]	[blank]	[blank]
Emergency Room Visits	[required row]
Observation Visits	[required row]
Observation Days	[required row]
Ambulatory Surgeries	[required row]
Clinic Visits	[required row]
Other Outpatient Visits	[required row]
Staffing	-	[blank]	[blank]	[blank]	[blank]
Total Full-Time Equivalents (4)	[required row]
Acute Hospital Provider Number(s) and CMS Star Rating(s)	[blank]	[blank]	[blank]	[blank]	[blank]
Enter all acute hospital CMS Certification Numbers (CCN) for the Borrower in Column B, and all CMS Star Ratings (if applicable) in columns C, D, E, F, for the respective quarters:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of CCNs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
CCN #1	(ENTER CCN HERE)
[placeholder row for CCN #2]	(ENTER CCN HERE)
[placeholder row for CCN #3]	(ENTER CCN HERE)
[placeholder row for CCN #4]	(ENTER CCN HERE)
[placeholder row for CCN #5]	(ENTER CCN HERE)
[placeholder row for CCN #6]	(ENTER CCN HERE)
[placeholder row for CCN #7]	(ENTER CCN HERE)
Long-Term Care Facility(ies) Owned / Pledged:	[blank]	[blank]	[blank]	[blank]	[blank]
If the Borrower owns, and/or has pledged as security under its FHA-insured mortgage, a Skilled Nursing (SNF), Nursing Home (NF), or Assisted Living facility (ALF), please provide:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of SNFs / NFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
SNF / NF #1 - Occupancy	(ENTER CCN HERE)
SNF / NF #1 - CMS Star Rating	[blank]
[placeholder row for SNF/NF #2 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #2 CMS Star Rating]	[blank]
[placeholder row for SNF/NF #3 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #3 CMS Star Rating]	[blank]
Number of ALFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
ALF #1 - Occupancy	-
[placeholder row for ALF #2 Occupancy]	-
[placeholder row for ALF #3 Occupancy]	-
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
[blank row]
1.	Does the Borrower plan to undertake, or has the Borrower undertaken any major changes involving the Mortgaged Property (renovation, relocation, addition or deletion of services) necessitating HUD review per the Regulatory Agreement or Security Instrument? For example, prior HUD approval is typically required for major facility changes necessitating building permits, for splitting or combining tax parcels, before establishing condominium regimes, before changing zoning, or changing the use of Mortgaged Property. Please review your executed loan documents for Notice provisions.
[Question 1 continued]	Quarter	YES or NO	Brief Explanation
[Question 1 continued]	1st Quarter	Please select…
[Question 1 continued]	2nd Quarter	Please select…
[Question 1 continued]	3rd Quarter	Please select…
[Question 1 continued]	4th Quarter	Please select…
[blank row]
2.	Has the Borrower identified any negative trends in service utilization statistics, financial indicators or ratios? Significant drops in financial performance can trigger the need for additional reporting to HUD. Please review your Regulatory Agreement.
[Question 2 continued]	Quarter	YES or NO	Brief Explanation
[Question 2 continued]	1st Quarter	Please select…
[Question 2 continued]	2nd Quarter	Please select…
[Question 2 continued]	3rd Quarter	Please select…
[Question 2 continued]	4th Quarter	Please select…
[blank row]
3.	Have there been any significant changes to the Borrower's operations or strategy (i.e. service line additions or deletions, divestitures, acquisitions, joint ventures, mergers, management contracts)? Some actions require prior approval of HUD. Please review your Regulatory Agreement.
[Question 3 continued]	Quarter	YES or NO	Brief Explanation
[Question 3 continued]	1st Quarter	Please select…
[Question 3 continued]	2nd Quarter	Please select…
[Question 3 continued]	3rd Quarter	Please select…
[Question 3 continued]	4th Quarter	Please select…
[blank row]
4.	Has there been any change in Board membership or Executive Management? HUD requires the submission of Previous Participation (2530) forms for Controlling Participants. Please see Processing Guide for Previous Participation Reviews of Prospective Multifamily Housing and Healthcare Programs’ Participants and contact your Account Executive. https://www.hud.gov/program_offices/housing/mfh/prevparticipation
[Question 4 continued]	Quarter	YES or NO	Brief Explanation
[Question 4 continued]	1st Quarter	Please select…
[Question 4 continued]	2nd Quarter	Please select…
[Question 4 continued]	3rd Quarter	Please select…
[Question 4 continued]	4th Quarter	Please select…
[blank row]
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5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants (applicable for Borrowers that executed an older version of the Regulatory Agreement)? Have actions or events triggered or required waivers or approvals from any financial institutions or other third parties for violating financial, negative or reporting covenants?
[Question 5 continued]	Quarter	YES or NO	Brief Explanation
[Question 5 continued]	1st Quarter	Please select…
[Question 5 continued]	2nd Quarter	Please select…
[Question 5 continued]	3rd Quarter	Please select…
[Question 5 continued]	4th Quarter	Please select…
[blank row]
6.	Has the Borrower received notice of an investigation, action, or charge by any federal, state, municipal and or other regulatory authority that could result in substantial liabilities or otherwise harm the creditworthiness of the Borrower? This includes, but is not limited to, an investigation, action or charge that demonstrates or alleges substantial deficiencies which may be evidenced by an administrative or judicial proceeding or audit finding, including actions taken by the United States Department of Justice or Office of Inspector General. Written notification to HUD is typically required when such a notice is received, please review your Regulatory Agreement.
[Question 6 continued]	Quarter	YES or NO	Brief Explanation
[Question 6 continued]	1st Quarter	Please select…
[Question 6 continued]	2nd Quarter	Please select…
[Question 6 continued]	3rd Quarter	Please select…
[Question 6 continued]	4th Quarter	Please select…
[blank row]
Certification from Authorized Representative
I hereby certify that I have read the financial statements and supplementary information of [ENTER BORROWER LEGAL NAME HERE] supplied within this form, and to the best of my knowledge and belief, the same are complete and accurate.
TYPE NAME OF AUTHORIZED REPRESENTATIVE OF BORROWER
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense may be recorded as a separate line item, depending on FASB/GASB reporting standards.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks
Edit Checks	-	Edit Satisfied for col 1?	Edit Satisfied for col 2?	Edit Satisfied for col 3?	Edit Satisfied for col 4?
Balance Sheet	-
A16+A17=A18	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20=A21	-	Yes	Yes	Yes	Yes
A21+A22+A23+A24+A25+A28+A29+A30=A31	-	Yes	Yes	Yes	Yes
A32+A33+A34+A35+A36=A37	-	Yes	Yes	Yes	Yes
A38+A39+A40=A41	-	Yes	Yes	Yes	Yes
A37+A41=A42	-	Yes	Yes	Yes	Yes
A43+A44=A45	-	Yes	Yes	Yes	Yes
A42+A45=A46	-	Yes	Yes	Yes	Yes
A31=A46	-	Yes	Yes	Yes	Yes
Income Statement	-
A48+A49=A50	-	Yes	Yes	Yes	Yes
A50+A51+A53=A54	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61+A62=A63	-	Yes	Yes	Yes	Yes
A64+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A68+A69+A70+A71=A72	-	Yes	Yes	Yes	Yes
A88+A89+A90+A91+A92=A48	-	Yes	Yes	Yes	Yes
Various Edit Checks	-
A52<=A54	-	Yes	Yes	Yes	Yes
A54-A63+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61<=A63	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20<=A21	-	Yes	Yes	Yes	Yes
A21+A25+A28<=A31	-	Yes	Yes	Yes	Yes
A31=A42+A43+A44	-	Yes	Yes	Yes	Yes
A32+A33+A34<=A37	-	Yes	Yes	Yes	Yes
A37+A38<=A42	-	Yes	Yes	Yes	Yes
Enter the Total Net assets from Prior Year		[blank]	[blank]	[blank]	[blank]
IF(ABS(($B$240+A68+A69+A70+A71)-C45)<=100,"Yes","No"	-	Yes	Yes	Yes	Yes
Reasonableness Review for Cost per Discharge	[blank]	-	-	-	-

---

Sheet 5: Monthly Reporting - 1st Qtr

[Sheet content highlights: primary data table A14; Other Information section A151; Certification section A200; footnotes A206; Edit Checks section A213]
OMB Approval No. 2502-0602 (Exp. XX/XX/202X) form HUD-92422-OHF
Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
[ENTER BORROWER LEGAL NAME HERE]			[ENTER FYE HERE]
If monthly reporting is required enter 1, if quarterly enter 2				1
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website www.hud.gov/healthcare or may be obtained from your Account Executive.
(B.) Please contact your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in YELLOW. Items in GREEN are to be filled out only if applicable
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) The Borrower is required to submit this form for only the Borrower, not the Borrower and other entities. If Assets, Liabilities, Equity, Revenues, or Expenses are excluded from the Borrower (not pledged under the security agreement), then those amounts should not be represented.
(G.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description		1st Month YTD	2nd Month YTD	3rd Month YTD	Do not Use - Start New Spreadsheet
Balance Sheet	[blank]	[blank]	[blank]	[blank]	[blank]
Cash & Temporary Investments	[required row]
Gross Patient Receivables	[required row]
Allowances for Contractual Deductions and Doubtful Accounts	[required row]
Net Accounts Receivable	-	$-	$-	$-	$-
Due from Related Entities	[required row]
All Other Current Assets	[required row]
Total Current Assets	-	$-	$-	$-	$-
Qualified Liquid Investments	[required row]
Hospital Held Non-Liquid Qual. Invest.	[required row]
Limited Use or Designated Assets	[required row]
Mortgage Reserve Fund - Trust Balance
Gross Property, Plant & Equipment	[required row]
Accumulated Depreciation	[required row]
Net Property, Plant & Equipment	-	$-	$-	$-	$-
Due from Related Entities (Long-Term)	[required row]
All Other Non-current Assets	[required row]
Total Assets	-	$-	$-	$-	$-
Accounts Payable	[required row]
Accrued Expenses	[required row]
Current Portion of LT Debts and Leases	[required row]
Due to Related Entities	[required row]
All Other Current Liabilities	[required row]
Total Current Liabilities	-	$-	$-	$-	$-
Long Term Debt and Leases	[required row]
Due to Related Entities (Long-Term)	[required row]
All Other Long Term Liabilities	[required row]
Total Long Term Liabilities	-	$-	$-	$-	$-
Total Liabilities	-	$-	$-	$-	$-
Net Assets without Donor Restrictions	[required row]
Net Assets with Donor Restrictions	[required row]
Total Net Assets	-	$-	$-	$-	$-
Total Net Assets + Total Liabilities	-	$-	$-	$-	$-
Income Statement	[blank]	[blank]	[blank]	[blank]	[blank]
Net Inpatient Revenue (1) (6)	[required row]
Net Outpatient Revenue (1) (6)	[required row]
Patient Service Rev net of Contr. Allow. & discounts	-	$-	$-	$-	$-
Provision for Bad Debts	[required row]
Net Patient Service Revenue less Provision for Bad Debts	-	$-	$-	$-	$-
All Other Operating Revenue	[required row]
Total Operating Revenue	-	$-	$-	$-	$-
Salaries and Wages	[required row]
Employee Benefits	[required row]
Contract Labor (clinical and non clinical) Expense	[required row]
Supplies and Pharmaceuticals Expense	[required row]
Depreciation Expense (incl Lease Amortization)	[required row]
Interest Expense	[required row]
Bad Debt Expense (1)	[required row]
All Other Operating Expenses	[required row]
Total Operating Expense	-	$-	$-	$-	$-
Income from Operations	-	$-	$-	$-	$-
All Non-Operating Revenue	[required row]
All Non-Operating Expense	[required row]
Extraordinary Items & Income Tax	[required row]
Net Income	-	$-	$-	$-	$-
Unrecognized Gains/Losses	[required row]
Changes in Restricted Net Assets	[required row]
Other Changes in Fund Balance (2)	[required row]
Net Increase/Decrease in Fund Balance	-	$-	$-	$-	$-
Mortgage Reserve Fund	-	[blank]	[blank]	[blank]	[blank]
Required MRF Balance	[required row]
Actual MRF Balance	-	$-	$-	$-	$-
FHA-Insured Mortgage	-	[blank]	[blank]	[blank]	[blank]
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages	[required row]
Credit Line Usage	-	[blank]	[blank]	[blank]	[blank]
If the Borrower maintains a credit line, provide:	-	[blank]	[blank]	[blank]	[blank]
Security Type (Cash, Investments, Accounts Receivable, Other)	[Row to be filled out only if applicable]	Please select…	Please select…	Please select…	Please select…
Credit Line Amount (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Current Balance Drawn (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Distribution of Assets and Surplus Cash	-	[blank]	[blank]	[blank]	[blank]
If the Borrower has made a Distribution of Assets or a distribution of Surplus Cash (either through specific approval by HUD or via certification of compliance with the Regulatory Agreement), as defined by the Regulatory Agreement, provide the total amount per quarter:	[Row to be filled out only if applicable]
Recurring County or Local Support	-	[blank]	[blank]	[blank]	[blank]
If the Borrower receives recurring county or local financial support, please indicate the amount received. Examples include recurring millage-based payment, or recurring direct payments in support of certain programs.	[Row to be filled out only if applicable]
Net Inpatient Revenue (1)	-	$-	$-	$-	$-
Medicare (including Managed Care)	[required row]
Medicaid (including Managed Care)	[required row]
Commercial Insurance (including non-governmental Managed Care)	[required row]
Self Pay	[required row]
Other	[required row]
Inpatient Statistics	-	[blank]	[blank]	[blank]	[blank]
Total Licensed Inpatient Beds	[required row]
Total Staffed Inpatient Beds	[required row]
Acute Medical/Surgical Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Newborn Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Acute Care Services	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Non-Acute Care	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Swing Bed (SNF)	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Acute Care Only (Excl. Newborn)	-	[blank]	[blank]	[blank]	[blank]
Medicare	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
All Patients	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
Outpatient Utilization	-	[blank]	[blank]	[blank]	[blank]
Emergency Room Visits	[required row]
Observation Visits	[required row]
Observation Days	[required row]
Ambulatory Surgeries	[required row]
Clinic Visits	[required row]
Other Outpatient Visits	[required row]
Staffing	-	[blank]	[blank]	[blank]	[blank]
Total Full-Time Equivalents (4)	[required row]
Acute Hospital Provider Number(s) and CMS Star Rating(s)	[blank]	[blank]	[blank]	[blank]	[blank]
Enter all acute hospital CMS Certification Numbers (CCN) for the Borrower in Column B, and all CMS Star Ratings (if applicable) in columns C, D, E, F, for the respective quarters:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of CCNs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
CCN #1	(ENTER CCN HERE)
[placeholder row for CCN #2]	(ENTER CCN HERE)
[placeholder row for CCN #3]	(ENTER CCN HERE)
[placeholder row for CCN #4]	(ENTER CCN HERE)
[placeholder row for CCN #5]	(ENTER CCN HERE)
[placeholder row for CCN #6]	(ENTER CCN HERE)
[placeholder row for CCN #7]	(ENTER CCN HERE)
Long-Term Care Facility(ies) Owned / Pledged:	[blank]	[blank]	[blank]	[blank]	[blank]
If the Borrower owns, and/or has pledged as security under its FHA-insured mortgage, a Skilled Nursing (SNF), Nursing Home (NF), or Assisted Living facility (ALF), please provide:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of SNFs / NFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
SNF / NF #1 - Occupancy	(ENTER CCN HERE)
SNF / NF #1 - CMS Star Rating	[blank]
[placeholder row for SNF/NF #2 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #2 CMS Star Rating]	[blank]
[placeholder row for SNF/NF #3 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #3 CMS Star Rating]	[blank]
Number of ALFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
ALF #1 - Occupancy	-
[placeholder row for ALF #2 Occupancy]	-
[placeholder row for ALF #3 Occupancy]	-
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
[blank row]
1.	Does the Borrower plan to undertake, or has the Borrower undertaken any major changes involving the Mortgaged Property (renovation, relocation, addition or deletion of services) necessitating HUD review per the Regulatory Agreement or Security Instrument? For example, prior HUD approval is typically required for major facility changes necessitating building permits, for splitting or combining tax parcels, before establishing condominium regimes, before changing zoning, or changing the use of Mortgaged Property. Please review your executed loan documents for Notice provisions.
[Question 1 continued]	Quarter	YES or NO	Brief Explanation
[Question 1 continued]	1st Month	Please select…
[Question 1 continued]	2nd Month	Please select…
[Question 1 continued]	3rd Month	Please select…
[Question 1 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
2.	Has the Borrower identified any negative trends in service utilization statistics, financial indicators or ratios? Significant drops in financial performance can trigger the need for additional reporting to HUD. Please review your Regulatory Agreement.
[Question 2 continued]	Quarter	YES or NO	Brief Explanation
[Question 2 continued]	1st Month	Please select…
[Question 2 continued]	2nd Month	Please select…
[Question 2 continued]	3rd Month	Please select…
[Question 2 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
3.	Have there been any significant changes to the Borrower's operations or strategy (i.e. service line additions or deletions, divestitures, acquisitions, joint ventures, mergers, management contracts)? Some actions require prior approval of HUD. Please review your Regulatory Agreement.
[Question 3 continued]	Quarter	YES or NO	Brief Explanation
[Question 3 continued]	1st Month	Please select…
[Question 3 continued]	2nd Month	Please select…
[Question 3 continued]	3rd Month	Please select…
[Question 3 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
4.	Has there been any change in Board membership or Executive Management? HUD requires the submission of Previous Participation (2530) forms for Controlling Participants. Please see Processing Guide for Previous Participation Reviews of Prospective Multifamily Housing and Healthcare Programs’ Participants and contact your Account Executive. https://www.hud.gov/program_offices/housing/mfh/prevparticipation
[Question 4 continued]	Quarter	YES or NO	Brief Explanation
[Question 4 continued]	1st Month	Please select…
[Question 4 continued]	2nd Month	Please select…
[Question 4 continued]	3rd Month	Please select…
[Question 4 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
[blank row]
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants (applicable for Borrowers that executed an older version of the Regulatory Agreement)? Have actions or events triggered or required waivers or approvals from any financial institutions or other third parties for violating financial, negative or reporting covenants?
[Question 5 continued]	Quarter	YES or NO	Brief Explanation
[Question 5 continued]	1st Month	Please select…
[Question 5 continued]	2nd Month	Please select…
[Question 5 continued]	3rd Month	Please select…
[Question 5 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
6.	Has the Borrower received notice of an investigation, action, or charge by any federal, state, municipal and or other regulatory authority that could result in substantial liabilities or otherwise harm the creditworthiness of the Borrower? This includes, but is not limited to, an investigation, action or charge that demonstrates or alleges substantial deficiencies which may be evidenced by an administrative or judicial proceeding or audit finding, including actions taken by the United States Department of Justice or Office of Inspector General. Written notification to HUD is typically required when such a notice is received, please review your Regulatory Agreement.
[Question 6 continued]	Quarter	YES or NO	Brief Explanation
[Question 6 continued]	1st Month	Please select…
[Question 6 continued]	2nd Month	Please select…
[Question 6 continued]	3rd Month	Please select…
[Question 6 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
Certification from Authorized Representative
I hereby certify that I have read the financial statements and supplementary information of [ENTER BORROWER LEGAL NAME HERE] supplied within this form, and to the best of my knowledge and belief, the same are complete and accurate.
TYPE NAME OF AUTHORIZED REPRESENTATIVE OF BORROWER
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense may be recorded as a separate line item, depending on FASB/GASB reporting standards.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks
Edit Checks	-	Edit Satisfied for col 1?	Edit Satisfied for col 2?	Edit Satisfied for col 3?	Edit Satisfied for col 4?
Balance Sheet	-
A16+A17=A18	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20=A21	-	Yes	Yes	Yes	Yes
A21+A22+A23+A24+A25+A28+A29+A30=A31	-	Yes	Yes	Yes	Yes
A32+A33+A34+A35+A36=A37	-	Yes	Yes	Yes	Yes
A38+A39+A40=A41	-	Yes	Yes	Yes	Yes
A37+A41=A42	-	Yes	Yes	Yes	Yes
A43+A44=A45	-	Yes	Yes	Yes	Yes
A42+A45=A46	-	Yes	Yes	Yes	Yes
A31=A46	-	Yes	Yes	Yes	Yes
Income Statement	-
A48+A49=A50	-	Yes	Yes	Yes	Yes
A50+A51+A53=A54	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61+A62=A63	-	Yes	Yes	Yes	Yes
A64+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A68+A69+A70+A71=A72	-	Yes	Yes	Yes	Yes
A88+A89+A90+A91+A92=A48	-	Yes	Yes	Yes	Yes
Various Edit Checks	-
A52<=A54	-	Yes	Yes	Yes	Yes
A54-A63+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61<=A63	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20<=A21	-	Yes	Yes	Yes	Yes
A21+A25+A28<=A31	-	Yes	Yes	Yes	Yes
A31=A42+A43+A44	-	Yes	Yes	Yes	Yes
A32+A33+A34<=A37	-	Yes	Yes	Yes	Yes
A37+A38<=A42	-	Yes	Yes	Yes	Yes
Enter the Total Net assets from Prior Year		[blank]	[blank]	[blank]	[blank]
IF(ABS(($B$240+A68+A69+A70+A71)-C45)<=100,"Yes","No"	-	Yes	Yes	Yes	Yes
Reasonableness Review for Cost per Discharge	[blank]	-	-	-	-

---

Sheet 6: Monthly Reporting - 2nd Qtr

[Sheet content highlights: primary data table A14; Other Information section A151; Certification section A200; footnotes A206; Edit Checks section A213]
OMB Approval No. 2502-0602 (Exp. XX/XX/202X) form HUD-92422-OHF
Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
[ENTER BORROWER LEGAL NAME HERE]			[ENTER FYE HERE]
If monthly reporting is required enter 1, if quarterly enter 2				1
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website www.hud.gov/healthcare or may be obtained from your Account Executive.
(B.) Please contact your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in YELLOW. Items in GREEN are to be filled out only if applicable
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) The Borrower is required to submit this form for only the Borrower, not the Borrower and other entities. If Assets, Liabilities, Equity, Revenues, or Expenses are excluded from the Borrower (not pledged under the security agreement), then those amounts should not be represented.
(G.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description		4th Month YTD	5th Month YTD	6th Month YTD	Do not Use - Start New Spreadsheet
Balance Sheet	[blank]	[blank]	[blank]	[blank]	[blank]
Cash & Temporary Investments	[required row]
Gross Patient Receivables	[required row]
Allowances for Contractual Deductions and Doubtful Accounts	[required row]
Net Accounts Receivable	-	$-	$-	$-	$-
Due from Related Entities	[required row]
All Other Current Assets	[required row]
Total Current Assets	-	$-	$-	$-	$-
Qualified Liquid Investments	[required row]
Hospital Held Non-Liquid Qual. Invest.	[required row]
Limited Use or Designated Assets	[required row]
Mortgage Reserve Fund - Trust Balance
Gross Property, Plant & Equipment	[required row]
Accumulated Depreciation	[required row]
Net Property, Plant & Equipment	-	$-	$-	$-	$-
Due from Related Entities (Long-Term)	[required row]
All Other Non-current Assets	[required row]
Total Assets	-	$-	$-	$-	$-
Accounts Payable	[required row]
Accrued Expenses	[required row]
Current Portion of LT Debts and Leases	[required row]
Due to Related Entities	[required row]
All Other Current Liabilities	[required row]
Total Current Liabilities	-	$-	$-	$-	$-
Long Term Debt and Leases	[required row]
Due to Related Entities (Long-Term)	[required row]
All Other Long Term Liabilities	[required row]
Total Long Term Liabilities	-	$-	$-	$-	$-
Total Liabilities	-	$-	$-	$-	$-
Net Assets without Donor Restrictions	[required row]
Net Assets with Donor Restrictions	[required row]
Total Net Assets	-	$-	$-	$-	$-
Total Net Assets + Total Liabilities	-	$-	$-	$-	$-
Income Statement	[blank]	[blank]	[blank]	[blank]	[blank]
Net Inpatient Revenue (1) (6)	[required row]
Net Outpatient Revenue (1) (6)	[required row]
Patient Service Rev net of Contr. Allow. & discounts	-	$-	$-	$-	$-
Provision for Bad Debts	[required row]
Net Patient Service Revenue less Provision for Bad Debts	-	$-	$-	$-	$-
All Other Operating Revenue	[required row]
Total Operating Revenue	-	$-	$-	$-	$-
Salaries and Wages	[required row]
Employee Benefits	[required row]
Contract Labor (clinical and non clinical) Expense	[required row]
Supplies and Pharmaceuticals Expense	[required row]
Depreciation Expense (incl Lease Amortization)	[required row]
Interest Expense	[required row]
Bad Debt Expense (1)	[required row]
All Other Operating Expenses	[required row]
Total Operating Expense	-	$-	$-	$-	$-
Income from Operations	-	$-	$-	$-	$-
All Non-Operating Revenue	[required row]
All Non-Operating Expense	[required row]
Extraordinary Items & Income Tax	[required row]
Net Income	-	$-	$-	$-	$-
Unrecognized Gains/Losses	[required row]
Changes in Restricted Net Assets	[required row]
Other Changes in Fund Balance (2)	[required row]
Net Increase/Decrease in Fund Balance	-	$-	$-	$-	$-
Mortgage Reserve Fund	-	[blank]	[blank]	[blank]	[blank]
Required MRF Balance	[required row]
Actual MRF Balance	-	$-	$-	$-	$-
FHA-Insured Mortgage	-	[blank]	[blank]	[blank]	[blank]
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages	[required row]
Credit Line Usage	-	[blank]	[blank]	[blank]	[blank]
If the Borrower maintains a credit line, provide:	-	[blank]	[blank]	[blank]	[blank]
Security Type (Cash, Investments, Accounts Receivable, Other)	[Row to be filled out only if applicable]	Please select…	Please select…	Please select…	Please select…
Credit Line Amount (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Current Balance Drawn (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Distribution of Assets and Surplus Cash	-	[blank]	[blank]	[blank]	[blank]
If the Borrower has made a Distribution of Assets or a distribution of Surplus Cash (either through specific approval by HUD or via certification of compliance with the Regulatory Agreement), as defined by the Regulatory Agreement, provide the total amount per quarter:	[Row to be filled out only if applicable]
Recurring County or Local Support	-	[blank]	[blank]	[blank]	[blank]
If the Borrower receives recurring county or local financial support, please indicate the amount received. Examples include recurring millage-based payment, or recurring direct payments in support of certain programs.	[Row to be filled out only if applicable]
Net Inpatient Revenue (1)	-	$-	$-	$-	$-
Medicare (including Managed Care)	[required row]
Medicaid (including Managed Care)	[required row]
Commercial Insurance (including non-governmental Managed Care)	[required row]
Self Pay	[required row]
Other	[required row]
Inpatient Statistics	-	[blank]	[blank]	[blank]	[blank]
Total Licensed Inpatient Beds	[required row]
Total Staffed Inpatient Beds	[required row]
Acute Medical/Surgical Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Newborn Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Acute Care Services	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Non-Acute Care	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Swing Bed (SNF)	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Acute Care Only (Excl. Newborn)	-	[blank]	[blank]	[blank]	[blank]
Medicare	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
All Patients	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
Outpatient Utilization	-	[blank]	[blank]	[blank]	[blank]
Emergency Room Visits	[required row]
Observation Visits	[required row]
Observation Days	[required row]
Ambulatory Surgeries	[required row]
Clinic Visits	[required row]
Other Outpatient Visits	[required row]
Staffing	-	[blank]	[blank]	[blank]	[blank]
Total Full-Time Equivalents (4)	[required row]
Acute Hospital Provider Number(s) and CMS Star Rating(s)	[blank]	[blank]	[blank]	[blank]	[blank]
Enter all acute hospital CMS Certification Numbers (CCN) for the Borrower in Column B, and all CMS Star Ratings (if applicable) in columns C, D, E, F, for the respective quarters:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of CCNs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
CCN #1	(ENTER CCN HERE)
[placeholder row for CCN #2]	(ENTER CCN HERE)
[placeholder row for CCN #3]	(ENTER CCN HERE)
[placeholder row for CCN #4]	(ENTER CCN HERE)
[placeholder row for CCN #5]	(ENTER CCN HERE)
[placeholder row for CCN #6]	(ENTER CCN HERE)
[placeholder row for CCN #7]	(ENTER CCN HERE)
Long-Term Care Facility(ies) Owned / Pledged:	[blank]	[blank]	[blank]	[blank]	[blank]
If the Borrower owns, and/or has pledged as security under its FHA-insured mortgage, a Skilled Nursing (SNF), Nursing Home (NF), or Assisted Living facility (ALF), please provide:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of SNFs / NFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
SNF / NF #1 - Occupancy	(ENTER CCN HERE)
SNF / NF #1 - CMS Star Rating	[blank]
[placeholder row for SNF/NF #2 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #2 CMS Star Rating]	[blank]
[placeholder row for SNF/NF #3 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #3 CMS Star Rating]	[blank]
Number of ALFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
ALF #1 - Occupancy	-
[placeholder row for ALF #2 Occupancy]	-
[placeholder row for ALF #3 Occupancy]	-
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
[blank row]
1.	Does the Borrower plan to undertake, or has the Borrower undertaken any major changes involving the Mortgaged Property (renovation, relocation, addition or deletion of services) necessitating HUD review per the Regulatory Agreement or Security Instrument? For example, prior HUD approval is typically required for major facility changes necessitating building permits, for splitting or combining tax parcels, before establishing condominium regimes, before changing zoning, or changing the use of Mortgaged Property. Please review your executed loan documents for Notice provisions.
[Question 1 continued]	Quarter	YES or NO	Brief Explanation
[Question 1 continued]	4th Month	Please select…
[Question 1 continued]	5th Month	Please select…
[Question 1 continued]	6th Month	Please select…
[Question 1 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
2.	Has the Borrower identified any negative trends in service utilization statistics, financial indicators or ratios? Significant drops in financial performance can trigger the need for additional reporting to HUD. Please review your Regulatory Agreement.
[Question 2 continued]	Quarter	YES or NO	Brief Explanation
[Question 2 continued]	4th Month	Please select…
[Question 2 continued]	5th Month	Please select…
[Question 2 continued]	6th Month	Please select…
[Question 2 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
3.	Have there been any significant changes to the Borrower's operations or strategy (i.e. service line additions or deletions, divestitures, acquisitions, joint ventures, mergers, management contracts)? Some actions require prior approval of HUD. Please review your Regulatory Agreement.
[Question 3 continued]	Quarter	YES or NO	Brief Explanation
[Question 3 continued]	4th Month	Please select…
[Question 3 continued]	5th Month	Please select…
[Question 3 continued]	6th Month	Please select…
[Question 3 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
4.	Has there been any change in Board membership or Executive Management? HUD requires the submission of Previous Participation (2530) forms for Controlling Participants. Please see Processing Guide for Previous Participation Reviews of Prospective Multifamily Housing and Healthcare Programs’ Participants and contact your Account Executive. https://www.hud.gov/program_offices/housing/mfh/prevparticipation
[Question 4 continued]	Quarter	YES or NO	Brief Explanation
[Question 4 continued]	4th Month	Please select…
[Question 4 continued]	5th Month	Please select…
[Question 4 continued]	6th Month	Please select…
[Question 4 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
[blank row]
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants (applicable for Borrowers that executed an older version of the Regulatory Agreement)? Have actions or events triggered or required waivers or approvals from any financial institutions or other third parties for violating financial, negative or reporting covenants?
[Question 5 continued]	Quarter	YES or NO	Brief Explanation
[Question 5 continued]	4th Month	Please select…
[Question 5 continued]	5th Month	Please select…
[Question 5 continued]	6th Month	Please select…
[Question 5 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
6.	Has the Borrower received notice of an investigation, action, or charge by any federal, state, municipal and or other regulatory authority that could result in substantial liabilities or otherwise harm the creditworthiness of the Borrower? This includes, but is not limited to, an investigation, action or charge that demonstrates or alleges substantial deficiencies which may be evidenced by an administrative or judicial proceeding or audit finding, including actions taken by the United States Department of Justice or Office of Inspector General. Written notification to HUD is typically required when such a notice is received, please review your Regulatory Agreement.
[Question 6 continued]	Quarter	YES or NO	Brief Explanation
[Question 6 continued]	4th Month	Please select…
[Question 6 continued]	5th Month	Please select…
[Question 6 continued]	6th Month	Please select…
[Question 6 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
Certification from Authorized Representative
I hereby certify that I have read the financial statements and supplementary information of [ENTER BORROWER LEGAL NAME HERE] supplied within this form, and to the best of my knowledge and belief, the same are complete and accurate.
TYPE NAME OF AUTHORIZED REPRESENTATIVE OF BORROWER
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense may be recorded as a separate line item, depending on FASB/GASB reporting standards.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks
Edit Checks	-	Edit Satisfied for col 1?	Edit Satisfied for col 2?	Edit Satisfied for col 3?	Edit Satisfied for col 4?
Balance Sheet	-
A16+A17=A18	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20=A21	-	Yes	Yes	Yes	Yes
A21+A22+A23+A24+A25+A28+A29+A30=A31	-	Yes	Yes	Yes	Yes
A32+A33+A34+A35+A36=A37	-	Yes	Yes	Yes	Yes
A38+A39+A40=A41	-	Yes	Yes	Yes	Yes
A37+A41=A42	-	Yes	Yes	Yes	Yes
A43+A44=A45	-	Yes	Yes	Yes	Yes
A42+A45=A46	-	Yes	Yes	Yes	Yes
A31=A46	-	Yes	Yes	Yes	Yes
Income Statement	-
A48+A49=A50	-	Yes	Yes	Yes	Yes
A50+A51+A53=A54	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61+A62=A63	-	Yes	Yes	Yes	Yes
A64+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A68+A69+A70+A71=A72	-	Yes	Yes	Yes	Yes
A88+A89+A90+A91+A92=A48	-	Yes	Yes	Yes	Yes
Various Edit Checks	-
A52<=A54	-	Yes	Yes	Yes	Yes
A54-A63+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61<=A63	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20<=A21	-	Yes	Yes	Yes	Yes
A21+A25+A28<=A31	-	Yes	Yes	Yes	Yes
A31=A42+A43+A44	-	Yes	Yes	Yes	Yes
A32+A33+A34<=A37	-	Yes	Yes	Yes	Yes
A37+A38<=A42	-	Yes	Yes	Yes	Yes
Enter the Total Net assets from Prior Year		[blank]	[blank]	[blank]	[blank]
IF(ABS(($B$240+A68+A69+A70+A71)-C45)<=100,"Yes","No"	-	Yes	Yes	Yes	Yes
Reasonableness Review for Cost per Discharge	[blank]	-	-	-	-

---

Sheet 7: Monthly Reporting - 3rd Qtr

[Sheet content highlights: primary data table A14; Other Information section A151; Certification section A200; footnotes A206; Edit Checks section A213]
OMB Approval No. 2502-0602 (Exp. XX/XX/202X) form HUD-92422-OHF
Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
[ENTER BORROWER LEGAL NAME HERE]			[ENTER FYE HERE]
If monthly reporting is required enter 1, if quarterly enter 2				1
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website www.hud.gov/healthcare or may be obtained from your Account Executive.
(B.) Please contact your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in YELLOW. Items in GREEN are to be filled out only if applicable
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) The Borrower is required to submit this form for only the Borrower, not the Borrower and other entities. If Assets, Liabilities, Equity, Revenues, or Expenses are excluded from the Borrower (not pledged under the security agreement), then those amounts should not be represented.
(G.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description		7th Month YTD	8th Month YTD	9th Month YTD	Do not Use - Start New Spreadsheet
Balance Sheet	[blank]	[blank]	[blank]	[blank]	[blank]
Cash & Temporary Investments	[required row]
Gross Patient Receivables	[required row]
Allowances for Contractual Deductions and Doubtful Accounts	[required row]
Net Accounts Receivable	-	$-	$-	$-	$-
Due from Related Entities	[required row]
All Other Current Assets	[required row]
Total Current Assets	-	$-	$-	$-	$-
Qualified Liquid Investments	[required row]
Hospital Held Non-Liquid Qual. Invest.	[required row]
Limited Use or Designated Assets	[required row]
Mortgage Reserve Fund - Trust Balance
Gross Property, Plant & Equipment	[required row]
Accumulated Depreciation	[required row]
Net Property, Plant & Equipment	-	$-	$-	$-	$-
Due from Related Entities (Long-Term)	[required row]
All Other Non-current Assets	[required row]
Total Assets	-	$-	$-	$-	$-
Accounts Payable	[required row]
Accrued Expenses	[required row]
Current Portion of LT Debts and Leases	[required row]
Due to Related Entities	[required row]
All Other Current Liabilities	[required row]
Total Current Liabilities	-	$-	$-	$-	$-
Long Term Debt and Leases	[required row]
Due to Related Entities (Long-Term)	[required row]
All Other Long Term Liabilities	[required row]
Total Long Term Liabilities	-	$-	$-	$-	$-
Total Liabilities	-	$-	$-	$-	$-
Net Assets without Donor Restrictions	[required row]
Net Assets with Donor Restrictions	[required row]
Total Net Assets	-	$-	$-	$-	$-
Total Net Assets + Total Liabilities	-	$-	$-	$-	$-
Income Statement	[blank]	[blank]	[blank]	[blank]	[blank]
Net Inpatient Revenue (1) (6)	[required row]
Net Outpatient Revenue (1) (6)	[required row]
Patient Service Rev net of Contr. Allow. & discounts	-	$-	$-	$-	$-
Provision for Bad Debts	[required row]
Net Patient Service Revenue less Provision for Bad Debts	-	$-	$-	$-	$-
All Other Operating Revenue	[required row]
Total Operating Revenue	-	$-	$-	$-	$-
Salaries and Wages	[required row]
Employee Benefits	[required row]
Contract Labor (clinical and non clinical) Expense	[required row]
Supplies and Pharmaceuticals Expense	[required row]
Depreciation Expense (incl Lease Amortization)	[required row]
Interest Expense	[required row]
Bad Debt Expense (1)	[required row]
All Other Operating Expenses	[required row]
Total Operating Expense	-	$-	$-	$-	$-
Income from Operations	-	$-	$-	$-	$-
All Non-Operating Revenue	[required row]
All Non-Operating Expense	[required row]
Extraordinary Items & Income Tax	[required row]
Net Income	-	$-	$-	$-	$-
Unrecognized Gains/Losses	[required row]
Changes in Restricted Net Assets	[required row]
Other Changes in Fund Balance (2)	[required row]
Net Increase/Decrease in Fund Balance	-	$-	$-	$-	$-
Mortgage Reserve Fund	-	[blank]	[blank]	[blank]	[blank]
Required MRF Balance	[required row]
Actual MRF Balance	-	$-	$-	$-	$-
FHA-Insured Mortgage	-	[blank]	[blank]	[blank]	[blank]
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages	[required row]
Credit Line Usage	-	[blank]	[blank]	[blank]	[blank]
If the Borrower maintains a credit line, provide:	-	[blank]	[blank]	[blank]	[blank]
Security Type (Cash, Investments, Accounts Receivable, Other)	[Row to be filled out only if applicable]	Please select…	Please select…	Please select…	Please select…
Credit Line Amount (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Current Balance Drawn (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Distribution of Assets and Surplus Cash	-	[blank]	[blank]	[blank]	[blank]
If the Borrower has made a Distribution of Assets or a distribution of Surplus Cash (either through specific approval by HUD or via certification of compliance with the Regulatory Agreement), as defined by the Regulatory Agreement, provide the total amount per quarter:	[Row to be filled out only if applicable]
Recurring County or Local Support	-	[blank]	[blank]	[blank]	[blank]
If the Borrower receives recurring county or local financial support, please indicate the amount received. Examples include recurring millage-based payment, or recurring direct payments in support of certain programs.	[Row to be filled out only if applicable]
Net Inpatient Revenue (1)	-	$-	$-	$-	$-
Medicare (including Managed Care)	[required row]
Medicaid (including Managed Care)	[required row]
Commercial Insurance (including non-governmental Managed Care)	[required row]
Self Pay	[required row]
Other	[required row]
Inpatient Statistics	-	[blank]	[blank]	[blank]	[blank]
Total Licensed Inpatient Beds	[required row]
Total Staffed Inpatient Beds	[required row]
Acute Medical/Surgical Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Newborn Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Acute Care Services	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Non-Acute Care	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Swing Bed (SNF)	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Acute Care Only (Excl. Newborn)	-	[blank]	[blank]	[blank]	[blank]
Medicare	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
All Patients	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
Outpatient Utilization	-	[blank]	[blank]	[blank]	[blank]
Emergency Room Visits	[required row]
Observation Visits	[required row]
Observation Days	[required row]
Ambulatory Surgeries	[required row]
Clinic Visits	[required row]
Other Outpatient Visits	[required row]
Staffing	-	[blank]	[blank]	[blank]	[blank]
Total Full-Time Equivalents (4)	[required row]
Acute Hospital Provider Number(s) and CMS Star Rating(s)	[blank]	[blank]	[blank]	[blank]	[blank]
Enter all acute hospital CMS Certification Numbers (CCN) for the Borrower in Column B, and all CMS Star Ratings (if applicable) in columns C, D, E, F, for the respective quarters:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of CCNs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
CCN #1	(ENTER CCN HERE)
[placeholder row for CCN #2]	(ENTER CCN HERE)
[placeholder row for CCN #3]	(ENTER CCN HERE)
[placeholder row for CCN #4]	(ENTER CCN HERE)
[placeholder row for CCN #5]	(ENTER CCN HERE)
[placeholder row for CCN #6]	(ENTER CCN HERE)
[placeholder row for CCN #7]	(ENTER CCN HERE)
Long-Term Care Facility(ies) Owned / Pledged:	[blank]	[blank]	[blank]	[blank]	[blank]
If the Borrower owns, and/or has pledged as security under its FHA-insured mortgage, a Skilled Nursing (SNF), Nursing Home (NF), or Assisted Living facility (ALF), please provide:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of SNFs / NFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
SNF / NF #1 - Occupancy	(ENTER CCN HERE)
SNF / NF #1 - CMS Star Rating	[blank]
[placeholder row for SNF/NF #2 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #2 CMS Star Rating]	[blank]
[placeholder row for SNF/NF #3 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #3 CMS Star Rating]	[blank]
Number of ALFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
ALF #1 - Occupancy	-
[placeholder row for ALF #2 Occupancy]	-
[placeholder row for ALF #3 Occupancy]	-
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
[blank row]
1.	Does the Borrower plan to undertake, or has the Borrower undertaken any major changes involving the Mortgaged Property (renovation, relocation, addition or deletion of services) necessitating HUD review per the Regulatory Agreement or Security Instrument? For example, prior HUD approval is typically required for major facility changes necessitating building permits, for splitting or combining tax parcels, before establishing condominium regimes, before changing zoning, or changing the use of Mortgaged Property. Please review your executed loan documents for Notice provisions.
[Question 1 continued]	Quarter	YES or NO	Brief Explanation
[Question 1 continued]	7th Month	Please select…
[Question 1 continued]	8th Month	Please select…
[Question 1 continued]	9th Month	Please select…
[Question 1 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
2.	Has the Borrower identified any negative trends in service utilization statistics, financial indicators or ratios? Significant drops in financial performance can trigger the need for additional reporting to HUD. Please review your Regulatory Agreement.
[Question 2 continued]	Quarter	YES or NO	Brief Explanation
[Question 2 continued]	7th Month	Please select…
[Question 2 continued]	8th Month	Please select…
[Question 2 continued]	9th Month	Please select…
[Question 2 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
3.	Have there been any significant changes to the Borrower's operations or strategy (i.e. service line additions or deletions, divestitures, acquisitions, joint ventures, mergers, management contracts)? Some actions require prior approval of HUD. Please review your Regulatory Agreement.
[Question 3 continued]	Quarter	YES or NO	Brief Explanation
[Question 3 continued]	7th Month	Please select…
[Question 3 continued]	8th Month	Please select…
[Question 3 continued]	9th Month	Please select…
[Question 3 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
4.	Has there been any change in Board membership or Executive Management? HUD requires the submission of Previous Participation (2530) forms for Controlling Participants. Please see Processing Guide for Previous Participation Reviews of Prospective Multifamily Housing and Healthcare Programs’ Participants and contact your Account Executive. https://www.hud.gov/program_offices/housing/mfh/prevparticipation
[Question 4 continued]	Quarter	YES or NO	Brief Explanation
[Question 4 continued]	7th Month	Please select…
[Question 4 continued]	8th Month	Please select…
[Question 4 continued]	9th Month	Please select…
[Question 4 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
[blank row]
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants (applicable for Borrowers that executed an older version of the Regulatory Agreement)? Have actions or events triggered or required waivers or approvals from any financial institutions or other third parties for violating financial, negative or reporting covenants?
[Question 5 continued]	Quarter	YES or NO	Brief Explanation
[Question 5 continued]	7th Month	Please select…
[Question 5 continued]	8th Month	Please select…
[Question 5 continued]	9th Month	Please select…
[Question 5 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
6.	Has the Borrower received notice of an investigation, action, or charge by any federal, state, municipal and or other regulatory authority that could result in substantial liabilities or otherwise harm the creditworthiness of the Borrower? This includes, but is not limited to, an investigation, action or charge that demonstrates or alleges substantial deficiencies which may be evidenced by an administrative or judicial proceeding or audit finding, including actions taken by the United States Department of Justice or Office of Inspector General. Written notification to HUD is typically required when such a notice is received, please review your Regulatory Agreement.
[Question 6 continued]	Quarter	YES or NO	Brief Explanation
[Question 6 continued]	7th Month	Please select…
[Question 6 continued]	8th Month	Please select…
[Question 6 continued]	9th Month	Please select…
[Question 6 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
Certification from Authorized Representative
I hereby certify that I have read the financial statements and supplementary information of [ENTER BORROWER LEGAL NAME HERE] supplied within this form, and to the best of my knowledge and belief, the same are complete and accurate.
TYPE NAME OF AUTHORIZED REPRESENTATIVE OF BORROWER
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense may be recorded as a separate line item, depending on FASB/GASB reporting standards.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks
Edit Checks	-	Edit Satisfied for col 1?	Edit Satisfied for col 2?	Edit Satisfied for col 3?	Edit Satisfied for col 4?
Balance Sheet	-
A16+A17=A18	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20=A21	-	Yes	Yes	Yes	Yes
A21+A22+A23+A24+A25+A28+A29+A30=A31	-	Yes	Yes	Yes	Yes
A32+A33+A34+A35+A36=A37	-	Yes	Yes	Yes	Yes
A38+A39+A40=A41	-	Yes	Yes	Yes	Yes
A37+A41=A42	-	Yes	Yes	Yes	Yes
A43+A44=A45	-	Yes	Yes	Yes	Yes
A42+A45=A46	-	Yes	Yes	Yes	Yes
A31=A46	-	Yes	Yes	Yes	Yes
Income Statement	-
A48+A49=A50	-	Yes	Yes	Yes	Yes
A50+A51+A53=A54	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61+A62=A63	-	Yes	Yes	Yes	Yes
A64+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A68+A69+A70+A71=A72	-	Yes	Yes	Yes	Yes
A88+A89+A90+A91+A92=A48	-	Yes	Yes	Yes	Yes
Various Edit Checks	-
A52<=A54	-	Yes	Yes	Yes	Yes
A54-A63+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61<=A63	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20<=A21	-	Yes	Yes	Yes	Yes
A21+A25+A28<=A31	-	Yes	Yes	Yes	Yes
A31=A42+A43+A44	-	Yes	Yes	Yes	Yes
A32+A33+A34<=A37	-	Yes	Yes	Yes	Yes
A37+A38<=A42	-	Yes	Yes	Yes	Yes
Enter the Total Net assets from Prior Year		[blank]	[blank]	[blank]	[blank]
IF(ABS(($B$240+A68+A69+A70+A71)-C45)<=100,"Yes","No"	-	Yes	Yes	Yes	Yes
Reasonableness Review for Cost per Discharge	[blank]	-	-	-	-

---

Sheet 8: Monthly Reporting - 4th Qtr

[Sheet content highlights: primary data table A14; Other Information section A151; Certification section A200; footnotes A206; Edit Checks section A213]
OMB Approval No. 2502-0602 (Exp. XX/XX/202X) form HUD-92422-OHF
Section 242 Mortgage Insurance for Hospitals Program FINANCIAL AND STATISTICAL DATA FOR HUD REPORTING
[ENTER BORROWER LEGAL NAME HERE]			[ENTER FYE HERE]
If monthly reporting is required enter 1, if quarterly enter 2				1
Instructions:
(A.) This form should be filed electronically using the most recent official OHF spreadsheet which is available on the OHF website www.hud.gov/healthcare or may be obtained from your Account Executive.
(B.) Please contact your OHF Account Executive for any clarifications.
(C.) For the FY quarter that you are completing, a value must be entered for all cells highlighted in YELLOW. Items in GREEN are to be filled out only if applicable
(D.) All line items in your financials must be summarized on this worksheet (e.g., if you have a current asset on your balance sheet and there is no specific line on this worksheet for it, then it should be included in "All Other Current Assets").
(E.) Footnotes, which provide an explanation of some lines, are located at bottom of sheet
(F.) The Borrower is required to submit this form for only the Borrower, not the Borrower and other entities. If Assets, Liabilities, Equity, Revenues, or Expenses are excluded from the Borrower (not pledged under the security agreement), then those amounts should not be represented.
(G.) IMPORTANT: Input for the Balance Sheet and Income Statement Sections may be deemed OPTIONAL by HUD for Borrowers that can provide ALL of the following datapoints via internally prepared submissions (i.e. direct output from the Borrower's financial system). Please discuss with your Account Executive.
Description		10th Month YTD	11th Month YTD	12th Month YTD	Do not Use - Start New Spreadsheet
Balance Sheet	[blank]	[blank]	[blank]	[blank]	[blank]
Cash & Temporary Investments	[required row]
Gross Patient Receivables	[required row]
Allowances for Contractual Deductions and Doubtful Accounts	[required row]
Net Accounts Receivable	-	$-	$-	$-	$-
Due from Related Entities	[required row]
All Other Current Assets	[required row]
Total Current Assets	-	$-	$-	$-	$-
Qualified Liquid Investments	[required row]
Hospital Held Non-Liquid Qual. Invest.	[required row]
Limited Use or Designated Assets	[required row]
Mortgage Reserve Fund - Trust Balance
Gross Property, Plant & Equipment	[required row]
Accumulated Depreciation	[required row]
Net Property, Plant & Equipment	-	$-	$-	$-	$-
Due from Related Entities (Long-Term)	[required row]
All Other Non-current Assets	[required row]
Total Assets	-	$-	$-	$-	$-
Accounts Payable	[required row]
Accrued Expenses	[required row]
Current Portion of LT Debts and Leases	[required row]
Due to Related Entities	[required row]
All Other Current Liabilities	[required row]
Total Current Liabilities	-	$-	$-	$-	$-
Long Term Debt and Leases	[required row]
Due to Related Entities (Long-Term)	[required row]
All Other Long Term Liabilities	[required row]
Total Long Term Liabilities	-	$-	$-	$-	$-
Total Liabilities	-	$-	$-	$-	$-
Net Assets without Donor Restrictions	[required row]
Net Assets with Donor Restrictions	[required row]
Total Net Assets	-	$-	$-	$-	$-
Total Net Assets + Total Liabilities	-	$-	$-	$-	$-
Income Statement	[blank]	[blank]	[blank]	[blank]	[blank]
Net Inpatient Revenue (1) (6)	[required row]
Net Outpatient Revenue (1) (6)	[required row]
Patient Service Rev net of Contr. Allow. & discounts	-	$-	$-	$-	$-
Provision for Bad Debts	[required row]
Net Patient Service Revenue less Provision for Bad Debts	-	$-	$-	$-	$-
All Other Operating Revenue	[required row]
Total Operating Revenue	-	$-	$-	$-	$-
Salaries and Wages	[required row]
Employee Benefits	[required row]
Contract Labor (clinical and non clinical) Expense	[required row]
Supplies and Pharmaceuticals Expense	[required row]
Depreciation Expense (incl Lease Amortization)	[required row]
Interest Expense	[required row]
Bad Debt Expense (1)	[required row]
All Other Operating Expenses	[required row]
Total Operating Expense	-	$-	$-	$-	$-
Income from Operations	-	$-	$-	$-	$-
All Non-Operating Revenue	[required row]
All Non-Operating Expense	[required row]
Extraordinary Items & Income Tax	[required row]
Net Income	-	$-	$-	$-	$-
Unrecognized Gains/Losses	[required row]
Changes in Restricted Net Assets	[required row]
Other Changes in Fund Balance (2)	[required row]
Net Increase/Decrease in Fund Balance	-	$-	$-	$-	$-
Mortgage Reserve Fund	-	[blank]	[blank]	[blank]	[blank]
Required MRF Balance	[required row]
Actual MRF Balance	-	$-	$-	$-	$-
FHA-Insured Mortgage	-	[blank]	[blank]	[blank]	[blank]
Total Unpaid Principal Balance of ALL FHA-Insured Mortgages	[required row]
Credit Line Usage	-	[blank]	[blank]	[blank]	[blank]
If the Borrower maintains a credit line, provide:	-	[blank]	[blank]	[blank]	[blank]
Security Type (Cash, Investments, Accounts Receivable, Other)	[Row to be filled out only if applicable]	Please select…	Please select…	Please select…	Please select…
Credit Line Amount (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Current Balance Drawn (in aggregate if multiple lines)	[Row to be filled out only if applicable]
Distribution of Assets and Surplus Cash	-	[blank]	[blank]	[blank]	[blank]
If the Borrower has made a Distribution of Assets or a distribution of Surplus Cash (either through specific approval by HUD or via certification of compliance with the Regulatory Agreement), as defined by the Regulatory Agreement, provide the total amount per quarter:	[Row to be filled out only if applicable]
Recurring County or Local Support	-	[blank]	[blank]	[blank]	[blank]
If the Borrower receives recurring county or local financial support, please indicate the amount received. Examples include recurring millage-based payment, or recurring direct payments in support of certain programs.	[Row to be filled out only if applicable]
Net Inpatient Revenue (1)	-	$-	$-	$-	$-
Medicare (including Managed Care)	[required row]
Medicaid (including Managed Care)	[required row]
Commercial Insurance (including non-governmental Managed Care)	[required row]
Self Pay	[required row]
Other	[required row]
Inpatient Statistics	-	[blank]	[blank]	[blank]	[blank]
Total Licensed Inpatient Beds	[required row]
Total Staffed Inpatient Beds	[required row]
Acute Medical/Surgical Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Newborn Service	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Acute Care Services	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Other Non-Acute Care	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Swing Bed (SNF)	-	[blank]	[blank]	[blank]	[blank]
Discharges	[required row]
Patient Days	[required row]
Acute Care Only (Excl. Newborn)	-	[blank]	[blank]	[blank]	[blank]
Medicare	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
All Patients	-	[blank]	[blank]	[blank]	[blank]
Case Mix Index (3)	[required row]
ALOS (5)	[required row]
Outpatient Utilization	-	[blank]	[blank]	[blank]	[blank]
Emergency Room Visits	[required row]
Observation Visits	[required row]
Observation Days	[required row]
Ambulatory Surgeries	[required row]
Clinic Visits	[required row]
Other Outpatient Visits	[required row]
Staffing	-	[blank]	[blank]	[blank]	[blank]
Total Full-Time Equivalents (4)	[required row]
Acute Hospital Provider Number(s) and CMS Star Rating(s)	[blank]	[blank]	[blank]	[blank]	[blank]
Enter all acute hospital CMS Certification Numbers (CCN) for the Borrower in Column B, and all CMS Star Ratings (if applicable) in columns C, D, E, F, for the respective quarters:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of CCNs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
CCN #1	(ENTER CCN HERE)
[placeholder row for CCN #2]	(ENTER CCN HERE)
[placeholder row for CCN #3]	(ENTER CCN HERE)
[placeholder row for CCN #4]	(ENTER CCN HERE)
[placeholder row for CCN #5]	(ENTER CCN HERE)
[placeholder row for CCN #6]	(ENTER CCN HERE)
[placeholder row for CCN #7]	(ENTER CCN HERE)
Long-Term Care Facility(ies) Owned / Pledged:	[blank]	[blank]	[blank]	[blank]	[blank]
If the Borrower owns, and/or has pledged as security under its FHA-insured mortgage, a Skilled Nursing (SNF), Nursing Home (NF), or Assisted Living facility (ALF), please provide:	[blank]	[blank]	[blank]	[blank]	[blank]
Number of SNFs / NFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
SNF / NF #1 - Occupancy	(ENTER CCN HERE)
SNF / NF #1 - CMS Star Rating	[blank]
[placeholder row for SNF/NF #2 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #2 CMS Star Rating]	[blank]
[placeholder row for SNF/NF #3 Occupancy]	(ENTER CCN HERE)
[placeholder row for SNF/NF #3 CMS Star Rating]	[blank]
Number of ALFs (Select from Drop-down):	Please select…	[blank]	[blank]	[blank]	[blank]
ALF #1 - Occupancy	-
[placeholder row for ALF #2 Occupancy]	-
[placeholder row for ALF #3 Occupancy]	-
Other Information: see questions below
Instructions:
Please Note - - For the questions below:
If the answer to any question is "NO", then enter "NO" in the yellow area for the appropriate quarter.
If the answer to any question is "YES", then enter a brief explanation in the yellow area for the appropriate quarter.
[blank row]
1.	Does the Borrower plan to undertake, or has the Borrower undertaken any major changes involving the Mortgaged Property (renovation, relocation, addition or deletion of services) necessitating HUD review per the Regulatory Agreement or Security Instrument? For example, prior HUD approval is typically required for major facility changes necessitating building permits, for splitting or combining tax parcels, before establishing condominium regimes, before changing zoning, or changing the use of Mortgaged Property. Please review your executed loan documents for Notice provisions.
[Question 1 continued]	Quarter	YES or NO	Brief Explanation
[Question 1 continued]	10th Month	Please select…
[Question 1 continued]	11th Month	Please select…
[Question 1 continued]	12th Month	Please select…
[Question 1 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
2.	Has the Borrower identified any negative trends in service utilization statistics, financial indicators or ratios? Significant drops in financial performance can trigger the need for additional reporting to HUD. Please review your Regulatory Agreement.
[Question 2 continued]	Quarter	YES or NO	Brief Explanation
[Question 2 continued]	10th Month	Please select…
[Question 2 continued]	11th Month	Please select…
[Question 2 continued]	12th Month	Please select…
[Question 2 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
3.	Have there been any significant changes to the Borrower's operations or strategy (i.e. service line additions or deletions, divestitures, acquisitions, joint ventures, mergers, management contracts)? Some actions require prior approval of HUD. Please review your Regulatory Agreement.
[Question 3 continued]	Quarter	YES or NO	Brief Explanation
[Question 3 continued]	10th Month	Please select…
[Question 3 continued]	11th Month	Please select…
[Question 3 continued]	12th Month	Please select…
[Question 3 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
4.	Has there been any change in Board membership or Executive Management? HUD requires the submission of Previous Participation (2530) forms for Controlling Participants. Please see Processing Guide for Previous Participation Reviews of Prospective Multifamily Housing and Healthcare Programs’ Participants and contact your Account Executive. https://www.hud.gov/program_offices/housing/mfh/prevparticipation
[Question 4 continued]	Quarter	YES or NO	Brief Explanation
[Question 4 continued]	10th Month	Please select…
[Question 4 continued]	11th Month	Please select…
[Question 4 continued]	12th Month	Please select…
[Question 4 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
[blank row]
5.	Is Management aware of any actions or events that could potentially violate HUD’s Regulatory Agreement or Covenants (applicable for Borrowers that executed an older version of the Regulatory Agreement)? Have actions or events triggered or required waivers or approvals from any financial institutions or other third parties for violating financial, negative or reporting covenants?
[Question 5 continued]	Quarter	YES or NO	Brief Explanation
[Question 5 continued]	10th Month	Please select…
[Question 5 continued]	11th Month	Please select…
[Question 5 continued]	12th Month	Please select…
[Question 5 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
6.	Has the Borrower received notice of an investigation, action, or charge by any federal, state, municipal and or other regulatory authority that could result in substantial liabilities or otherwise harm the creditworthiness of the Borrower? This includes, but is not limited to, an investigation, action or charge that demonstrates or alleges substantial deficiencies which may be evidenced by an administrative or judicial proceeding or audit finding, including actions taken by the United States Department of Justice or Office of Inspector General. Written notification to HUD is typically required when such a notice is received, please review your Regulatory Agreement.
[Question 6 continued]	Quarter	YES or NO	Brief Explanation
[Question 6 continued]	10th Month	Please select…
[Question 6 continued]	11th Month	Please select…
[Question 6 continued]	12th Month	Please select…
[Question 6 continued]	Do not Use - Start New Spreadsheet	Please select…
[blank row]
Certification from Authorized Representative
I hereby certify that I have read the financial statements and supplementary information of [ENTER BORROWER LEGAL NAME HERE] supplied within this form, and to the best of my knowledge and belief, the same are complete and accurate.
TYPE NAME OF AUTHORIZED REPRESENTATIVE OF BORROWER
The following applies to ALL hospitals
Footnotes:
(1) Bad Debt Expense may be recorded as a separate line item, depending on FASB/GASB reporting standards.
(2) Please provide an explanation for any "Other Changes in Fund Balance".
(3) Please enter using only 2 decimal points
(4) Please enter using only a whole number
(5) Please enter using only 1 decimal point
(6) These are estimates.
Edit Checks
Edit Checks	-	Edit Satisfied for col 1?	Edit Satisfied for col 2?	Edit Satisfied for col 3?	Edit Satisfied for col 4?
Balance Sheet	-
A16+A17=A18	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20=A21	-	Yes	Yes	Yes	Yes
A21+A22+A23+A24+A25+A28+A29+A30=A31	-	Yes	Yes	Yes	Yes
A32+A33+A34+A35+A36=A37	-	Yes	Yes	Yes	Yes
A38+A39+A40=A41	-	Yes	Yes	Yes	Yes
A37+A41=A42	-	Yes	Yes	Yes	Yes
A43+A44=A45	-	Yes	Yes	Yes	Yes
A42+A45=A46	-	Yes	Yes	Yes	Yes
A31=A46	-	Yes	Yes	Yes	Yes
Income Statement	-
A48+A49=A50	-	Yes	Yes	Yes	Yes
A50+A51+A53=A54	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61+A62=A63	-	Yes	Yes	Yes	Yes
A64+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A68+A69+A70+A71=A72	-	Yes	Yes	Yes	Yes
A88+A89+A90+A91+A92=A48	-	Yes	Yes	Yes	Yes
Various Edit Checks	-
A52<=A54	-	Yes	Yes	Yes	Yes
A54-A63+A65+A66+A67=A68	-	Yes	Yes	Yes	Yes
A55+A56+A57+A58+A59+A60+A61<=A63	-	Yes	Yes	Yes	Yes
A15+A18+A19+A20<=A21	-	Yes	Yes	Yes	Yes
A21+A25+A28<=A31	-	Yes	Yes	Yes	Yes
A31=A42+A43+A44	-	Yes	Yes	Yes	Yes
A32+A33+A34<=A37	-	Yes	Yes	Yes	Yes
A37+A38<=A42	-	Yes	Yes	Yes	Yes
Enter the Total Net assets from Prior Year		[blank]	[blank]	[blank]	[blank]
IF(ABS(($B$240+A68+A69+A70+A71)-C45)<=100,"Yes","No"	-	Yes	Yes	Yes	Yes
Reasonableness Review for Cost per Discharge	[blank]	-	-	-	-